Our analysis shows that while dose-sharing became an important source of vaccine supply for COVAX, it did not compensate for its procurement challenges, compromising COVAX’s ability to reach its original milestones. COVAX was only partially successful in persuading governments with excess vaccine doses to share these with its Facility, with many opting to donate all or some of their surplus vaccines through bilateral arrangements instead of through COVAX. Even for donations to COVAX, donor countries systematically broke COVAX’s dose-sharing principles, failing to deliver on most of their donation pledges within the requested period and then making ad hoc deliveries in ways that have made it exceedingly difficult for recipient countries to roll-out vaccination campaigns. Moreover, some countries’ earmarking of donations has complicated, and possibly compromised, COVAX’s fair allocation mechanism.
Below, we discuss how COVAX partners’ pursuit of national security, diplomatic and commercial interests undermined the effectiveness of COVAX’s dose-sharing mechanism. We then discuss how COVAX’s institutional design and governance largely accommodated these practices as part of a pragmatic attempt to get as many doses as possible within a context of widespread vaccine nationalism globally.
Unilateralism and national health security interests
Much like wealthy and vaccine-producing countries adopted unilateral strategies for vaccine procurement in 2020 to gain prioritized access for their citizens [5], the way they have donated vaccines has also often sought to safeguard national security interests. This finding is in line with two decades of scholarship on global health security showing that the national level remains the main referent object of security for Western countries’ engagement with epidemic preparedness and response [32, 33].
While making lofty pledges, donor countries largely held off sharing until doing so would not impact their citizens, with the UK for example, reassuring citizens that “the doses being donated are not needed for the domestic rollout” [34]. Moreover, even if rich countries were to fulfill their donation pledges, they would still be likely to accumulate enormous quantities of surplus vaccines throughout the first half of 2022. Such accumulation in itself constitutes a national preparedness policy that is referred to as “stockpiling,” and occurs at the expense of global vaccination efforts [35].
The US exemplifies how donations can be a way to, at once, demonstrate global solidarity and pursue national security interests. In the first half of 2021, the Defense Protection Act was mobilized to oblige American vaccine manufacturers to prioritize deliveries to the US government, resulting in virtually no exports or donations abroad. Even though the US regulatory agency did not approve the AstraZeneca vaccine for domestic use, it was nonetheless stockpiled [36]. Ahead of the G7 meeting in June 2021 – and as the American vaccination campaign plateaued due to vaccine hesitancy – President Joe Biden announced a deal with Pfizer to purchase one billion doses for COVAX “at cost,” including 700 million doses that would count as a “donation”. Unlike other countries, for whom “donation” meant a redistribution of surplus doses, the vast majority of the US “donation” is made up of doses specifically purchased for COVAX, a procurement by proxy of sort. This enabled the US to “donate” without impacting its own vaccine supply, to select the vaccine supplier (Pfizer, a US company) and to maintain strong production capacity for mRNA vaccines (and jobs) at home. In case of crisis or need of extra doses, the Defense Protection Act empowers the US government to redirect the future “donated” Pfizer doses for domestic use. The COVAX donation thus strengthened the US’s preparedness capacity, itself an important national security asset.
Influence, soft power & “vaccine diplomacy”
That wealthy countries adhered so poorly to COVAX’s dose-sharing principles also reflects that they used their COVAX donations not only to exercise solidarity, but also as a soft power tool to achieve diplomatic recognition and influence [8, 10], so-called “vaccine diplomacy”, and domestic political gain.
During the Covid-19 pandemic, vaccine diplomacy has most commonly been associated with China [37], where it has been seen as “a natural extension of Chinese soft power” [38] that has been used strategically for nation branding, building China’s reputation as a benevolent state and repairing its image following criticisms for its lack of transparency in the early days of the pandemic. Our finding that China donated all its doses bilaterally aligns with previous descriptions of China’s global health diplomacy as being “fundamentally state-centric” [39]. It is also consistent with China’s previous uses of medical diplomacy for hard (material benefits) and soft (image-building) power objectives, for example through sending Chinese medical teams to African countries [40]. In some cases, its bilateral vaccine donations have allegedly come with specific conditions attached. For example, Paraguay’s foreign ministry claims that China offered vaccine doses in exchange for the country breaking its diplomatic ties with Taiwan [41]. However, the scale of Chinese donations (82.7 million doses) is modest compared with the estimated billion doses the country has exported, a third of the doses China manufactured in 2021 [42]. China thus mainly sold its vaccines, including to COVAX, nuancing the importance of donations relative to sales in China’s “vaccine diplomacy” [43].
China’s ability to supply vaccines in Africa, where COVAX faltered, appears to have frustrated Western countries, whose major financial contributions and donation pledges to COVAX did not reap similar diplomatic gain. The quest for greater diplomatic influence helps to explain why the EU, in a first instance, donated a substantial share of doses outside of the initiative, despite supporting COVAX too. One of the justifications for the EU’s efforts to develop its own “targeted vaccine-sharing” with low-income and neighboring countries was to provide more visibility on the world stage [44]. EU documents state that although to the general COVAX approach means possible soft/regional targeting, "it implies rather limited visibility for member States, Team Europe and the European Union” [45]. The EU subsequently established a system to facilitate dose donations to countries associated with its European Neighborhood Policy, which aims at bringing the EU and its neighbors closer, such as countries from the Eastern partnership region [46]. The effort to persuade donors to channel doses to COVAX instead helps to explain why COVAX appears to have been increasingly willing to accommodate donors’ desire for a degree of earmarking and greater visibility [46].
Despite vaccine diplomacy often being associated with China, we found that virtually every donor country practiced a form of “vaccine diplomacy” in the context of vaccine donations, either through direct bilateral donations, or through COVAX, confirming previous research showing that Western countries, just like China, conceive of global health as a soft power tool. For instance, Gagnon and Labonté [47] concluded that the primary reason the UK integrated health into its foreign policy in the first place was self-interest, including security and economic interests, as well as “a way to enhance UK’s international reputation”. Western countries’ vaccine donations served to brand them as charitable “donors” motivated by global solidarity, distracting from the image civil society groups had painted of them as vaccine hoarders driven by national self-interest [48]. Countries’ frequent violation of COVAX’s dose-sharing principles suggests that they privileged short-term diplomatic recognition over maximizing the impact of their donations. In some senses, what had been a multilateral effort transformed into an opportunity for countries to display global solidarity while allowing them to reap diplomatic and reputational gains.
Commercial interests
The interplay between national security, diplomatic and commercial interests also compromised the effectiveness of COVAX’s dose-sharing scheme, a dimension often neglected in state-centric analyzes of global health security and global health diplomacy. Although COVAX's dose-sharing principles were addressed to both donor countries and vaccine manufacturers, vaccine manufacturers appear to have done little to enable their implementation. They did not donate any vaccine doses to COVAX, committing instead to sell it doses “at cost” through commercial deals. Overall, commercial manufacturers have prioritized the most lucrative markets and, when export restrictions were imposed, domestic markets [48]. This was for instance the case of the Serum Institute of India, which was initially supposed to provide most of COVAX’s supply of AstraZeneca vaccines before an export ban was imposed to prioritize supply to India. In November 2021, Bruce Aylward, senior advisor to the WHO Director General, vocally expressed frustration about the industry’s lack of transparency around delayed deliveries to COVAX: “Show us the queue. Where is the order? And how do you organize your queue? If it is by the order in which they were placed, then we would have been served a long time ago” [44].
We argue that promoting dose-sharing can be seen as a convenient strategy for the pharmaceutical industry to pursue its economic interests. First, instead of prioritizing “at cost” deliveries to COVAX, dose-sharing allows manufacturers to continue deliveries to their most lucrative markets and to maximize profits by selling doses at full price to wealthy countries, who can then share or donate them forward. Second, it enables industry to claim that production has been scaled up sufficiently to meet global demand but must simply be redistributed, deflecting attention from demands for a waiver on intellectual property on vaccines and other Covid-19 diagnostics and therapeutics at the World Trade Organization [49]. Third, it obscures the power the industry holds over the global allocation of vaccines, placing primary responsibility for redistribution (or failure to do so) on wealthy country governments.
When, in May 2021, IFPMA – the global voice or lobby of the pharmaceutical industry – endorsed dose-sharing as essential for vaccine equity, it committed to “immediately work with governments that have significant domestic supplies of Covid-19 vaccine doses to share a meaningful proportion of their doses with low- and lower-middle-income countries in a responsible and timely way through COVAX or other efficient established mechanisms” [50]. Contracts and negotiations over vaccine supply are confidential trade secrets, but media sources suggest that some vaccine companies impeded donations through contractual clauses. The New York Times reported in January 2021 that contracts for Covid-19 vaccine purchases prohibited donations [51]. After gaining access to leaked contracts, Vanity Fair reported that the US agreed in contracts with Pfizer, Moderna, AstraZeneca, and Johnson & Johnson (Janssen) that, “the Government may not use, or authorize the use of, any products or materials provided under this Project Agreement, unless such use occurs in the United States” [49]. The report cited government officials acknowledging that manufacturers had refused to negotiate this clause, but were complicit with this practice to secure advantageous conditions for domestic supply [49]. The contracts had to be renegotiated before doses could be sent abroad, due to liability issues: in case of an adverse side effect, who should be responsible? The buyer/donor? The manufacturer? Or the recipient country?
COVAX foresaw this “bottleneck” and offered a no-fault compensation scheme to cover cross-border liability hurdles. This COVAX liability scheme only covers doses directly sent from the manufacturing plant – i.e., that have not been delivered to the purchasing country. This partly explains why several countries that pledged to donate doses through COVAX channeled doses bilaterally instead. Despite COVAX’s offers, it reportedly took many months before manufacturers agreed to terms that would enable vaccine donations; 6 months or longer for separate agreements between the EU and Pfizer, Johnson & Johnson, and Moderna, resulting in agreements only in the third quarter of 2021 [52, 53]. The Norwegian diplomat who led the negotiations with Pfizer stated that “negotiations were more complicated than had been expected” [53].
Meanwhile, Germany wrote to the EU in late October 2021 to express frustration over “ongoing bureaucratic, logistical and legal problems imposed by vaccine makers on EU countries wanting to donate surplus shots”, which impede donations and may lead to wasting of vaccine doses [54]. For example, Moderna only agreed to terms that made it possible for the EU to donate 70 million vaccine doses through COVAX in mid-November 2021 [52]. These contractual impediments and delays raise questions about the degree of industry’s commitment to dose-sharing, and expose public officials’ failure to anticipate the extent and complexity of the legal impediments. The EU correctly claimed in 2020 that its APA with Moderna ensured that “member States can also decide to donate the vaccine to lower and middle-income countries or to re-direct it to other European countries” [55] but this applied only to bilateral donations. To share procured doses with COVAX it had to negotiate complementary agreements with individual manufacturers [53].
At the same time, that donor governments do not publicly challenge these inconsistencies may reflect that they have a self-interest in accommodating industry requirements, whether to ensure priority access and favorable terms for their own citizens, or to reap tax benefits from manufacturers’ profits. BioNTech, for example, is estimated to boost Germany’s Gross Domestic Product (GDP) by 0.5% in 2021 [56], will create jobs, and will generate important tax revenues – €3.1 billion for the first months of 2021 alone [57]. This may partly explain Germany’s solidarity with the pharmaceutical industry in opposing a waiver on their intellectual property rights.
COVAX and the limits of the ‘super PPP’ model to solve global health crises
COVAX’s leaders and supporters tend to blame “external factors” for the problems the initiative has encountered, while highlighting its pragmatism and flexibility to deliver vaccines despite hurdles [58]. Indeed, key partners did not play by the rules – or to be precise, the voluntary principles they committed to when joining COVAX – thereby undermining the initiative’s work. In addition, some countries (China, India, and Russia) did not contribute to COVAX’s dose-sharing and the US only joined the initiative late, under the Biden administration. However, many of the problems revealed by our analysis are home grown from within COVAX and derive from the initiative’s governance and institutional design, which limits the leverage that COVAX has to shape the behavior of donor states and the pharmaceutical industry.
First, and as we have argued elsewhere, the initiative was set-up as a “super-PPP” that tried to accommodate the divergent interests of its donors, suppliers, and recipients, resulting in an incredibly complex governance structure. This complexity blurs lines of accountability [13]. The boards of the respective participating institutions formally bear the ultimate responsibility for the organizations’ actions, but have no mandate for the overall COVAX initiative and these boards are dominated by donor governments and the pharmaceutical industry [59] – the same partners that undermined the initiative’s procurement efforts by pursuing their own self-interests. Donor governments and the industry have been able to wield power within the initiative to obtain the conditions they want, even when this was at odds with the goal of maximizing vaccine equity. The fact that COVAX has no mechanisms for enforcing its dose-sharing principles shows that the initiative’s institutional design is poorly suited to the challenges it faces. In the absence of other enforcement mechanisms, COVAX’s leaders continue to insist on voluntary principles. A year after publishing its dose-sharing principles, COVAX issued a joint statement with the African Union and the Africa Centre for Disease Control outlining a series of strikingly similar standards for dose donations, again “calling on” donors and manufacturers to “commit to this effort by adhering to the following standards, beginning from 1 January 2022” [60].
COVAX’s structure as a super-PPP has also enabled a critical lack of transparency. The lack of transparency relating to contracts with pharmaceutical companies, vaccine prices, subsidies for Research & Development and scaling up production capacity, etc. have been widely noted, and applies to dose-sharing too [61]. The case of earmarking vaccine donation is a clear example. Despite considerable efforts (see methods), we were unable to establish how the COVAX Facility reached its decision to permit earmarking, directly at odds with its stated principles. There is no mention of the issue of earmarking in the minutes of Gavi’s board meetings, which oversees the COVAX Facility, or in the publicly available minutes of meetings either of the AMC engagement group or of the Shareholders Council. The COVAX Coordination Meeting may have discussed the issue as it is the highest-level coordinating body within the initiative, but summaries of its discussions are not publicly available. Officials from the COVAX Facility did not answer our repeated enquiries about earmarking.
On the one hand, proponents have argued that without COVAX, vaccine inequity would be even worse [62]. On the other hand, it is problematic that its voluntary public-private partnership model appears to allow a culture of deference to the most powerful partners to keep them engaged. Instead of using naming and shaming tactics to deplore broken donation pledges or inadequate deliveries as it might have done, COVAX’s external communication has systematically praised its suppliers and “generous donors” [63], even when their donation practices complicated its equitable allocation proposals. This is doubly ironic since the donors are the same nation states that directly undermined the initiative’s procurement efforts by signing unilateral deals in 2020 (and beyond) that pushed COVAX to the back of the vaccine supply queue, making its goal of delivering two billion vaccines in 2021 unachievable. COVAX has also been mostly silent about the hurdles imposed by manufacturers. Despite the IAVG noting that “not all expected doses from COVAX advanced purchase agreements (APAs) have been honored by vaccine producers according to contractual obligations” [64], to our knowledge the COVAX Facility has not pursued legal action or other sanctions against the producers, in much the same way as COVAX co-lead CEPI did not sanction Moderna’s breach of its equitable access principles [65]. This contrasts with the EU, which took legal action against AstraZeneca after delays in vaccine deliveries [66].